Fractures
Fractures are significant soft tissue injuries that result in a break in a bone. The general approach to fracture management is similar regardless of the bone involved. It is crucial to obtain a thorough history and physical examination. Xrays are not 100% sensitive therefore a normal xray should not rule out pathology. History *Age, hand dominance *Mechanism *Other injuries *Events preceding *Events post-injury (ambulation, pain, swelling) *Previous injury *Last tetanus *PMHx (osteoporosis), Medications (steroid use, immunosuppression), Allergies *SHx: occupation, smoking (healing time) *Last meal *If clinical picture does not fit look proximal for injury Physical Examination *ABCs - ALWAYS!! *Open versus closed (skin integrity) *Neurovascular assessment *Examine joint above and joint below *Compare to opposite site *MSK examination Investigations *'Xray:' Ensure appropriate series, number of views (minimum 2 views at 90 degrees), and quality of films *Treat the patient and not the xray *'Most commonly missed fracture on the xray is the 2nd fracture' *'Ensure xrays pre and post- reduction' *'Bloodwork: '''CBC, INR, PTT, Type and screen +/- cross-match Description of a Fracture *Open versus closed *Location (proximal/middle/distal third) (epiphysis, metaphysis, diaphysis) *Intra or extra-articular *Fracture pattern: *Transverse (right angles to long axis of bone) *Oblique *Spiral: rotational force *Comminuted: more than 2 # fragments *Greenstick: incomplete # of one cortex *Dislocation: complete incongruity between articular surfaces of joint. Represents significant ligamentous injury or laxity. *NOTE: dislocations are uncommon in children as growth plates # before ligamentous injury *NOTE: dislocations are uncommon in elderly (as osteoporosis) likely to # *Subluxation: incomplete incongruity between articular surfaces of a joint *'Describe distal anatomy relative to the proximal ' *Displacement: incongruity of the ends of the bone at the site of a # (% not in contact) *Angulation: deviation form the anatomic axis of the bone (% distal fragment relative to proximal) *Shortening *Rotation: detected on clinical examination *Stable versus Unstable (inherent tendency to shift even with immobilization) Fracture Management *NPO *Early and adequate analgesics *Sling/splint *Xray *Reduction: obtain and maintain. Important to mold cast. *Pre and post-neurovascular examination and xray *+/- Orthopedics follow-up *Discharge instructions: RICE (restricted activity, ice, compression, elevation) *If open #: immediate orthopedics involvement, ensure tetanus is up to date, antibiotics **Cefazolin **+ aminoglycoside if dirty wound, comminuted #, contaminated, more soft tissue injury **Surgical irrigation and debridement Fracture Complications Early complications *Neurovascular injury *Compartment syndrome **Forearm and calf highest risk **Symptoms: 5's Pain (out of proportion and with passive stretch), Paresthesia, Pallor, Paralysis, Pulselessness **Treatment: remove external pressure, open fasciotomy, orthopedics consultation *Infection/Sepsis *DVT/PE *Hemorrhagic shock *Fat embolism Late complications *Delayed union, non-union, mal-union *Stiffness, contractures *Avascular necrosis *Osteomyelitis *Growth disturbance/deformity *Osteoarthritis (post-traumatic) *Complex regional pain syndrome: localized pain/swelling/stiffness, vasomotor dysfunction, skin changes *Hererotropic ossifcation: bone developing at abnormal sites Special considerations: (fractures with normal xrays) Scaphoid fractures *Mechanism: often FOOSH *Physical examination: pain in anatomical snuffbox *Investigations: xray often normal. Therefore on clinical suspicion. *Management: thumb spica spint and repeat xray in 14 days **Bone scan: positive in 3 days **MRI: positive in 24 hours **CT scan with 1mm cuts (less effective than bone scan or MRI) **Ensure orthopedics follow-up *Complications: non-union, avascular necrosis *Always refer if proximal pole involved, oblique fracture (unstable), displaced >1mm Growth Plate Fractures Salter Harris Classification: *'Be hesitate to make diagnosis of sprain in a child with open growth plates''' *Growth plate often # before the ligamentous injury occurs * Have a lower threshold to xray children *Children remodel well only in plane of range of motion of the joint closest to the fracture Elbow #'s *May appear as normal on initial xray *Suspect in patients with lateral elbow pain following FOOSH *Suspect radial head # if posterior fat pad visible on xray Stress #'s *May appear as normal on initial xray *History: repetitive stress, sudden increase in physical activity, gradual onset of pain *Physical Examination: focal tenderness at # site *Investigations: could consider MRI or bone scan *Management: often conservative Elderly patients *'CAUTION: with elderly patients with acute change in mobility with normal xrays. May represent occult fracture. Consider further imaging with CT scans or bone scans to r/o #' Hip Fractures *high morbidity and mortality *Often shortened and externally rotated *Xrays not 100% sensitive --> consider further imaging with CT/MRI Ottawa Ankle Rules Ottawa Knee Rules Canadian C-Spine Rule Resources www.orthobullets.com/ Radiology Masterclass -- check out trauma xrays here!